<div id="page">
    <div id="page-bgtop">
        <div id="content">
            <div class="post">
                <h2 class="title">Member Registration</h2>
                <div class="entry">
                    <span jwcid="errors"/>
                    <form jwcid="formRegisMember">
                        <table>
                            <tr>
                                <td>Username/email</td>
                                <td><input type="text" name="username" jwcid="username"/></td>
                            </tr>
                            <tr>
                                <td>Password</td>
                                <td><input type="text" name="pass" jwcid="pass"/></td>
                            </tr>

                            <tr>
                                <td>Name</td>
                                <td><input type="text" name="name" jwcid="name"/></td>
                            </tr>
                            <tr>
                                <td>Birth Date</td>
                                <td><input type="text" name="birth" jwcid="birth"/></td>
                            </tr>
                            <tr>
                                <td>Address</td>
                                <td><input type="text" name="address" jwcid="address"/></td>
                            </tr>
                            <tr>
                                <td>City</td>
                                <td><input type="text" name="city" jwcid="city"/></td>
                            </tr>
                            <tr>
                                <td>Province</td>
                                <td><input type="text" name="province" jwcid="province"/></td>
                            </tr>
                            <tr>
                                <td>Postcode</td>
                                <td><input type="text" name="post" jwcid="post"/></td>
                            </tr>
                            <tr>
                                <td>Phone</td>
                                <td><input type="text" name="phone" jwcid="phone"/></td>
                            </tr>
                            <tr>
                                <td>&nbsp;</td>
                                <td><input type="submit" value="Simpan"></td>
                            </tr>
                        </table>

                    </form>
                </div>
            </div>

        </div>

            
                    
		